RN Care Coordinator

About the role

Southwest Care Center (SCC) is a non-profit healthcare organization that has been providing exceptional healthcare to the community for over 25 years, offering medical, behavioral healthcare, and community outreach services from health centers in Santa Fe, Albuquerque, Farmington, and Roswell, NM. SCC is an FQHC‑LAL. They are currently seeking a Registered Nurse Care Coordinator for their Santa Fe, NM clinics, where primary and specialty care services are delivered at three locations. You will join a dynamic team of healthcare professionals committed to delivering outstanding care within Santa Fe’s diverse community.

Responsibilities

• Participate in the identification of high risk/high acuity patients.
• Identify and follow up on hospital and emergency department admissions and discharges.
• Oversee care transitions (hospital to home, hospital to rehabilitation center/nursing facility) and coordinate follow up with patient.
• Initiate patients' medication reconciliation.
• Oversee patients' linkages to community resources and social support.
• Closely coordinate and facilitate patients' care with primary care providers, behavioral health specialists and outside providers.
• Act as a patient advocate protecting privacy and confidentiality.
• Maintain a comprehensive working knowledge of community resources, payer requirements, and network services for target population.
• Promote patients’ independence by establishing patient care goals; teaching and counseling patient, friends, and family and reinforcing their understanding of disease, medications, and self‑care skills.
• Maintains a cooperative relationship among health care teams by communicating information; responding to requests; building rapport; participating in team problem‑solving methods.
• Models and supports development of Medical Assistants.
• Demonstrates prioritization, critical‑thinking and decision‑making skills.
• Offers insight and direction in dealing with clinical situations and responds accordingly.
• Embraces change that improves results and assists others through the change process.
• Acts as a team member and provides efficient patient care practices, collaborates with the health care team to assure a team approach.
• Conduct nurse visits to ensure patient care plan is followed.
• Communicates effectively in a timely manner.
• Maintains good working relationships with the health care team in solving problems/issues in delivery of services.
• Provides constructive feedback; resolves conflicts and issues in a timely manner and refers issues as appropriate.
• Maintains effective lines of communication with staff.
• Communicates significant clinical issues; keeps leadership apprised of workflow issues and supervisory activities.
• Contributes to developing and attaining long range objectives including, but not limited to: financial goals, operations improvement, quality improvement, resource utilization and clinical practice enhancements.
• Represents clinic on inter‑disciplinary committees/work groups.
• Identifies key performance indicators for self and team members and develops methods for reaching established goals and measurement of each.
• Participates in developmental and educational programs.

Benefits

Southwest Care Center offers a full benefits package including medical, dental, vision, life, long term and short‑term disability insurance, a 401(k) retirement fund, and CME reimbursement.

Schedule

Scheduled Weekly Hours: 40